ATTACHMENT 10- JAMES H. QUILLEN EMERGENCY NOTIFICATION PLAN.pdf

JAMES H. QUILLEN VA MEDICAL CENTER

MOUNTAIN HOME, TENNESSEE 37684

January 6, 2020

MEDICAL CENTER MEMORANDUM

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EMERGENCY NOTIFICATION PLAN

1. PURPOSE. This memorandum is published to provide procedural guidance for notifying the medical center Executive Leadership Team (EL T) and Veterans Integrated Service Network (VISN) office immediately in the event of a disaster, crisis, at-risk missing p-atient, sentinel event or untoward situation , including those with potential media, congressional or litigious implications at this facility and/or catchment area.

Notifications will be made for Disaster Drills and all unannounced surveys by VHA or other external accrediting agencies.

2. SCOPE. The contents of this memorandum apply to all organizational elements of James H. Quillen VA Medical Center (JHQVAMC). The medical center will ensure the timely review and update of all cascade call rosters associated with the Emergency Notification Plan .

3. POLICY. This policy establishes a streamlined communication method and identifies key staff to be notified of any significant event, close call , disaster, sentinel event or untoward situation with potential media, congressional or litigious implications.

The policy provides a mechanism to communicate that event, close call , disaster, sentinel event or untoward situation and information security issues to the EL T and the VISN 9 office. Staff is to immediately report any unusual occurrences, events that may be newsworthy, or incidents with unexpected outcomes to their supervisor, who will communicate this to the appropriate EL T member or the Chief of Quality Management.

Th is includes at-risk missing patients, sentinel events, disasters, or untoward situations including those with potential media, congressional or litigious implications.

4. ACTION/RESPONSIBILITY

a. Responsibilities of Medical Center Supervisors/Service Chiefs

The medical center staff will communicate immediately any unusual occurrences, events that may be newsworthy, or incidents with unexpected outcomes to their supervisor. The supervisor will call the Chief of Quality Management, the Patient Safety Manager, or the appropriate EL T member when the incidents described in paragraph one occurs. These incidents include but are not limited to:

(1) Unexpected patient death

MEDICAL CENTER MEMORANDUM

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(2) At-risk missing patient

(3) Criminal matters involving felonies to include, but not limited to, theft of

· government property over $1 ,000, false claims, drug offenses, crimes involving information technology systems, and serious crimes against a person, i.e. , homicides, armed robbery, rape, allegations of assault to include sexual assault, and serious physical abuse of a VA patient.

(4) Sentinel events or untoward situations, including those with potential media, congressional or litigious implications.

(5) Activation of the Emergency Management Plan , including drills.

b. Responsibilities of Medical Center Director or Designee

(1) Immediately forward an email to "VHAMOU Notification B Group" with additional information , which should include:

(a) Statement of Issue

(b) Background

(c) Current status

(d) Action(s)

(2) Communication may occur via phone to the appropriate VISN staff within 1 hour of learning of such event.

(3) E-mail communication within 1 hour of learning of ALL events to include a brief description of the incident, using the VHA Heads Up message format (Appendix B) sent to all the following . This communication should be sent as text pasted into an Outlook message AND as an attachment in the same Outlook email message (with no boxes) , with a message in the text version that the attachment is the same content:

(a) VISN 9 Notification

(b) For incidents involving information security, include the VISN Information Security Officer.

(c) For incidents involving any supplies or services provided by Acquisition and Logistics, include the VISN Chief Logistics Officer.

(d) For incidents involving mental health, include the VISN Mental Health Officer.

(4) Email communication of ALL events with complete details and the supporting documentation outlining the issue, background , and implications within 8 hours of learning of the event, using the VHA Issue Brief format (Appendix C) , sent only to the VISN 9 Notification B email group. This communication should be sent as text pasted into an Outlook message AND as an attachment in the same Outlook message (with no boxes) , with a message in the text version that the attachment is the same content.

(5) In addition to the above steps, additional reporting requirements for "Incidents Involving Personally Identifiable Information" include reporting security incidents to a Federal incident response center. All incidents involving personally identifiable information will be reported to United States Computer Emergency Readiness Team (US-CERT) within 1 hour of discovering the incident: In order for the Veterans Affairs Network and Security Operation Center (VA-NSOC) to meet the one-hour reporting requirement, it is imperative that all VHA offices immediately report all incidents involving personally identifiable information in electronic or physical form as soon as they are discovered. The incidents should be reported to the VA-NSOC via the Information Security Officer (ISO) or designee, and into the Privacy and Security Event Tracking System (PSETS) by the Privacy Officer (PO) , and should not distinguish between suspected and confirmed breaches. Employees may report incidents to the ISO or PO by email , voicemail or enter the issue into the Privacy and Security Web access from the JHQVAMC Intranet page via the "Programs" link.

(6) VA-NSOC reports described above should include a description of what corrective action will be taken (i.e., counseling plan to prevent future occurrences). This is required in order to close out the NSOC report. Issue Briefs are not necessary unless the information breach is of an urgent need for the VA Central Office to know. Issue Briefs are not necessary if the information breach remained within the VA system; the NSOC report should state that it remained internal and what local actions were taken. If the information breach took place outside the VA system, an Issue Brief should be prepared to describe these events and should include the NSOC report number in the subject line and text of the email.

c. Responsibilities of Medical Center Staff

(1) Medical center staff will notify frontline managers or supervisors of any event that would require initiation of an incident report, a health or safety risk, activation of the Medical Center Emergency Management Plan or any other incident described in Medical Center Memorandum "Patient Safety Improvement/Risk Management Programs." Supervisors/managers will then activate the medical center Notification Cascade Call Plan .

(2) Telephone contact should be initiated and continued until telephone contact is .

made with the frontline supervisor/manager or next contact on the medical center Notification Cascade Call Plan identified in Appendix A.

(3) Medical center staff completing the Heads Up and Issue Brief paperwork will minimize the use of acronyms or abbreviations, or wiUspell out the acronyms the first time they are used. When sending an Issue Alert or Issue Brief, in the subject line on the Outlook message, use the following guide:

(a) VHA Issue Brief V9 +Date+ Facility Name+ Subject keyword(s)

(b) Example: VHA Issue Brief V9-12-17-08 James H. Quillen VAMC -Patient Suicide

(4) When there is an update, incorporate that information at the very beginning (in a different color font) of the Issue Brief. When there are updates to an Issue Brief, put the word "Update" at the end of the subject line. Example: VHA Issue Brief V9-12-18-08 James H. Quillen VAMC-Patient Suicide UPDATE.

(5) The following template should be used when preparing an Issue Brief regarding suicidal behavior:

Type of self-harm (based on self-directed violence classification s stem nomenclature Known recent stressors that may have contributed to precipitating the event Brief summary of Mental Health care over past 2 years (include hospitalizations, residential care stays, evidence-based psychotherapies, the number of encounters, and other information as a ro riate Brief summary of medical/surgical care over past 2 years (include hospitalizations and other information as appropriate)

Date and type of last MH appointment

Date and type of last primary care/medical/surgical appointment

Were there recent no shows for either MH or medical/surgical appointments and was follow-up done?

Had suicide risk assessments been done within the past 2 years?

• When (most recent assessment before the event)?

• Determination?

Was the Veteran on the High Risk List within the past 2 years?

• If so - date(s) flag placed on medical record

• If so - date(s) flag deactivated

Had a safety plan been developed?

• If so, data of last update?

Date of Last Mental Health Screenin and Screenin Results

• PHQ-2 or PHQ-9

• PCL or PCL-5

• AUDIT-C

• Other (Specify)

Had the following been addressed in any way during the past 2 years? If so, provide a brief description

• Pain?

• Insomnia?

• Substance use?

List current mental health diagnoses

List of current medical surgical diagnoses

List current VA medications

List known non-VA medications

(6) All incidents reported related to VA employees should co1"1tain answers to the following Employee Standard Questions:

(a) Was person also a Veteran? (if yes, indicate which branch of Service if known)

(b) Was person an "employee" or was the person participating in some other work related program [such as compensated work therapy (CWT)]?

(c) What was the person's "job"? (Duty/job title or job responsibilities)

(d) What was the person's VHA entrance on duty (EOD) date? How long had they been a facility employee?

(e) Did the person have a complete National Agency Check with Written Inquiries (NACl)/background) check? (Yes/no - if yes, date of NACI; if not, has a NACI been initiated; if yes , date initiated)?

(f) Did the person have a Personal Identity Verification (PIV) card? (yes/no)

(g) Continuous Readiness Information Security Program (CRISP)/HSPD-12 related question: Has the supervisor (or other appropriate agency/actor) taken custody of the PIV card? (Alternative question - Has the PIV card been deactivated to preclude access to buildings/IT systems?)

(7) All incidents involving personally identifiable information , including reporting security incidents, will be immediately reported (within 1 hour) to frontline managers or supervisors who will notify a member of the EL T.

d. Disaster requiring implementation of the Emergency Management Plan

(1) Staff responsibilities. Implement the medical center Emergency Management Plan. The Emergency Management Coordinator, Safety Manager or EL T designee should complete a VHA Issue Brief and forward to the "VHAMOU Notification Group B" mail group.

(2) Medical Center Director Responsibilities.

(a) Implement Emergency Management Plan .

(b) The Medical Center Director, or designee, will implement the emergency notification procedures as instructed in VISN 9 Directive 1ON9-104-16 Emergency Operations Plan.

e. Clinical or Administrative Issues

( 1) Staff responsibilities

(a) Staff will notify managers/supervisors immediately via telephone or in person. In the event that the individual is not reached , the next person on the Medical Center Notification Cascade Call Plan is to be contacted until telephone contact is made with supervisory staff and will continue up through the service chiefs and EL T members to the Medical Center Director. The Public Affairs Officer, Chief, Quality Management, Patient Safety Officer, or EL T designee should complete Appendix C, VHA Issue Brief, and forward to the "VHAMOU Notification Group B" mail group.

(b) All employees are required to immediately report potential or actual criminal events to their immediate supervisor, upper level management, the Compliance and Business Integrity Officer (CBI Officer) , VA Police, or facility leadership. For any potential or actual criminal matters, VA Police or facility leadership will refer such matters to the VA Office of Inspector General (OIG) upon notification of such . All fact finding or investigative efforts will cease until the VA OIG provides guidance or instruction. After notification to the VA OIG, facility leadership will submit a Heads-Up promptly to the VISN Office and follow with a full Issue Brief (IB) within 24 hours. After review at the VISN level , the IB will be forwarded to VA Central Office with annotation of the date and time of VA OIG notification. In the event of a suspected felony the Chief, Police Service, is required to notify the VA OIG promptly. Examples of felonies include but are not limited to , theft of Government property valued over $1000, false claims, drug offenses, crimes involving information technology systems, and serious crimes against a person (i.e. , homicides, armed robbery, aggravated assault, and serious physical abuse of a VA patient) .

(2) Medical Center Director responsibilities. The Medical Center Director or designee will implement the emergency notification procedures, as instructed in accordance with VISN 9 protocol.

5. REFERENCES

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a. VISN 9 Directive 10N9-104-16, Emergency Operations Plan, June 30, 2016.

b. DUSHOM Memorandum - Referrals Regarding Criminal Violations , dated March 7, 2012.

c. DUSHOM Memorandum - Mandated Issue Brief submission for Operations for Procedure Cancellations Related to Reusable Medical Equipment, dated March 23, 2018.

d. 1 ON Guide to VHA Issue Briefs, March 29, 2018.

e. Notification Process Mid South Healthcare Network (VISN 9) , Standard Operating Procedure 10N9-SOP-18-14, dated April 9, 2018.

f. VA Directive 0321 Serious Incident Reports , June 6, 2012.

g. Medical Center Memorandum 00PS-17-01, Patient Safety Improvement Program and Patient Incident Reporting

6. RESCISSION: Medical Center Memorandum 00Q-1$-06

7. RECERTIFICATION DATE: January 5, 2025

8. FOLLOW-UP RESPONSIBILITY: Chief, Quality Management & Improvement Service (QM&IS) ti),/1). @)~

De~, MHSA, FACHE Medical Center Director

Attachments:

Appendix A- James H. Quillen VAMC Notification Plan Appendix B - VHA Heads Up Message Appendix C - VHA Issue Brief

MEDICAL CENTER MEMORANDUM 00Q-009

APPENDIX A

JAMES H. QUILLEN VAMC NOTIFICATION

CASCADE PLAN

Disasters, Clinical, or Administrative Issues:

Staff will notify managers/supervisors immediately via telephone or in person. In the event that the individual is not reached, the next person is to be contacted until telephone contact is made with supervisory staff on up through Service Chiefs, Chief, Quality Management, ELT members to the Medical Center Director. The Chief, Quality Management, or ELT designee should complete Appendix C, VHA issue brief and forward to each member of the Plan B Notification Cascade Call plan.

fublic Affairs Officer

(423) 926-1171 ext. 7126 +--

1st Line Manager/Supervisor l Service Chief/MAA

Chief, Quality Management & Improvement Service

(423) 979- 3617

ELTMEMBERS

Associate Director (AD)

(423) 926-1171 ext. 7104

Chief of Staff (COS)

(423) 926-1171 ext. 7116

Associate Director for Patient Care Services (ADPCS)

(423) 926- 1171 ext. 7213 l Medical Center Director

(Implement V9 Notification Directive) ( 423) 926-1171 ext. 7102

Patient Safety Manager ____. (423) 926-1171 ext. 7306

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APPENDIX B

VHA HEADS UP

1) Facility Name: Include site, parent facility (as appropriate), and VISN

2) What Occurred: Summarize incident in 3-5 sentences; the 1B following the incident should contain specific information. Include any immediate actions or resolutions that were taken.

3) When: Date and time of incident.

4) Have you notified other offices or programs? Yes or No (If Yes, identify the appropriate VHA Central Office program office that was notified).

5) Additional details will be provided by: When (within the next 24 hours).

6) If there are questions, please contact: Full name, position, location, phone number with area code and extension.

Email communication within one (1) hour of learning of the event to include a brief description of the incident, using the VHA Heads Up Notification format, sent to ALL of the following :

(a) VISN 9 Notification B email group

(b) Others as appropriate to the issue

a) Be specific and succinct - answer the question of who, what, when , where and why.

b) . Identify which medical center the issue brief is about.

c) Submit timely, immediately following the Issue Alert.

d) Clearly state status of situation and briefly annotate chronology of events.

e) Avoid use of acronyms; spell out abbreviations.

f) Minimize use of technical/medical terminology.

g) Do not use patient identifiers; i.e. names, SSNs, etc.

h) Include status/location of veteran , meaning outpatient, inpatient on type of ward etc. and when the veteran was last seen by VA provider.

i) Succinctly summarize issue(s).

j) Include status of planned corrective actions and target completion date.

k) Indicate any media, VSO or congressional involvement.

I) Note whether a Root Cause Analysis (RCA) or Board of Investigation (801) is to be conducted and its target date for completion.

m) Note whether OIG or other program offices within VA have been contacted .

This box contains directions for completing the process; please do not include it when you submit the Issue Brief or Issue Alert.

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APPENDIX C

VHA ISSUE BRIEF

VISN # - Name of facility and (Location)

Issue Title: Summary of issue in one sentence

Date of Report: Date of notification

Brief Statement of Issue and Status: Date of occurrence (if different from date of report), background information; what happened and what the current situation is, chronologically

Actions, Progress, and Resolution Date: Should chronologically include why this happened; what has been done to keep it from happening again; any media, VSO, and congressional involvement or interest

Indicate if Applicable: place an "X" next to the response reflecting the facility's action

• Institutional Disclosure __ YES; __ NO; ___ N/A

• Clinical Disclosure __ YES; __ NO; ___ N/A

Contact for Further Information: Name of subject matter expert, title, phone number with area code and extension

Email communication of ALL events with complete details and the supporting documentation outlining the issue, background, and implications within eight (8) hours of learning of the event, using the VHA Issue Brief format, sent only to the VISN 9 Notification B email group. This communication should be sent as text pasted into an Outlook message AND as an attachment in the same Outlook email message (with no boxes), with a message in the text version that the attachment is the same content. Per your discretion, Issue Briefs that contain sensitive information may be sent PKI.

a) Be specific and succinct - answer the question of who, what, when, where and why.

b) Identify which medical center the issue brief is about.

c) Submit timely, immediately following the Issue Alert.

d) Clearly state status of situation and briefly annotate chronology of events.

e) Avoid use of acronyms; spell out abbreviations.

f) Minimize use of technical/medical terminology.

g) Do not use patient identifiers; i.e. names, SSNs, etc.

h) Include status/location of veteran, meaning outpatient, inpatient on type of ward etc. and when the veteran was last seen by VA provider.

i) Succinctly summarize issue(s).

j) Include status of planned corrective actions and target completion date.

k) Indicate any media, VSO or congressional involvement.

I) Note whether a Root Cause Analysis (RCA) or Board of Investigation (801) is to be conducted and its target date for completion .

m) Note whether OIG or other program offices within VA have been contacted.

This box contains directions for completing the process; please do not include it when you submit the Issue.Brief or Issue Alert.

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